Certificate of Vision Impairment for people who are sight impaired (partially sighted) or severely sight impaired (blind) – Updated August 2017 Page 1 Part 1: Certificate of Vision Impairment Patient’s details Title and surname or family name All other names(identify preferred name) Address (including postcode) Telephone number Email address Date of Birth (dd/mm/yyyy)Sex (delete as appropriate) Female/Male/UnspecifiedNHS Number Page 2To be completed by the Ophthalmologist Tick the box that applies I consider that This person is sight impaired (partially sighted) This person is severely sight impaired (blind) I have made the patient aware of the information booklet “Sight Loss: What we needed to know” (www.rnib.org.uk/sightlossinfo) Yes/No - delete as appropriate Has the patient seen an Eye Clinic Liaison Officer (ECLO)/Sight Loss Advisor? Yes/Referred/Not available - delete as appropriate Signed Date of examination Name (print) Hospital address: NB: the date of examination is taken as the date from which any concessions are calculated For Hospital staff: Provide/send copies of this CVI as stated below An accessible signed copy of the CVI form to the patient (or parent/guardian if the patient is a child). Pages 1-5 to the patient’s local council if the patient (or parent/guardian if the patient is a child) consents, within 5 working days. Pages 1-5 to the patient’s GP, if the patient (or parent/guardian if the patient is a child) consents. Pages 1-6 to The Royal College of Ophthalmologists, c/o Certifications Office, Moorfields Eye Hospital, 162 City Road, London, EC1V 2PD, or by nhs.net secure email to meh-tr.CVI@nhs.net if the patient (or parent/guardian if the patient is a child) consents. Part 2: To be completed by the Ophthalmologist Visual function Right eye Left eye Binocular (Habitual) Best corrected visual acuity Field of vision Extensive loss of peripheral visual field (including hemianopia) Yes/No delete as appropriate Low vision service If appropriate, has a referral for the low vision service been made? Yes/No/Don’t know delete as appropriate Part 2a: Diagnosis (for patients 18 years of age or over) Tick each box that applies. Circle the main cause where there is more than one. ICD 10 code. Right eye. Left eye. Retina : age-related macular degeneration – choroidal neovascularisation (wet) H35.32 age-related macular degeneration – atrophic/geographic macular atrophy (dry) H35.31 age-related macular degeneration unspecified (mixed) H35.30 diabetic retinopathy E10.3-E14.3 H36.0 diabetic maculopathy H36.0 A hereditary retinal dystrophy H35.5 retinal vascular occlusions H34 other retinal (specify) H35 Glaucoma primary open angle H40.1 primary angle closure H40.2 secondary H40.5 other glaucoma (specify) H40 Globe degenerative myopia H44.2 Neuro-logical optic atrophy H47.2 visual cortex disorder H47.6 cerebrovascular disease I60-I69 Choroid chorioretinitis H30.9 choroidal degeneration H31.1 Lens cataract (excludes congenital) H25.9 Corneacorneal scars and opacities H17 keratitis H16 Neoplasia eye C69 brain & CNS C70-C72,D43-D44 other neoplasia (specify) C00-C68, C73-C97, D00-D42, D45-D48 Diagnosis not covered in any of the above,specify, including ICD 10 code if known *Please note that this is not intended to be a comprehensive list of all possible diagnoses. Page 3 Part 2b: Diagnosis (for patients under the age of 18) Tick each box that applies. Circle the main cause if there is more than one. ICD 10 code. Right eye. Left eye. Central Visual Pathway Problems cerebral/cortical pathology affecting mainly a) acuity b) fields c) visual perception (circle) H47.6 nystagmus H55 other (specify) H47.7 Whole Globe and Anterior Segmentanophthalmos/microphthalmos Q11 disorganised globe/phthisis H44 anterior segment anomaly Q13 primary congenital/infantile glaucoma Q15, H40.1-H40.2 other glaucoma H40.8-H40.9 Amblyopia stimulus deprivation H53.0 strabismic H53.0 refractive H53.0 Cornea opacity H17 dystrophy H18.4 other(specify) H18.8-H18.9 Cataractcongenital Q12.0 developmental H26.9 secondary H26.4 Uvea aniridia Q13.1 coloboma Q12.2, Q13.0 uveitis H20 other (specify) H21 Retinaretinopathy of prematurity H35.1 retinal dystrophy H35.5 retinitis H30 other retinopathy H35.2 retinoblastoma C69.2 albinism E70.3 retinal detachment H33 other(specify) H35 Optic Nerve hypoplasia Q11.2 other congenital anomaly Q14.2 optic atrophy H47.2 neuropathy H47.0 other(specify) H47.0 Diagnosis not covered in any of the above,specify,including ICD 10 code if known Page 4 Part 3: To be completed by the patient (or parent/guardian if the patient is a child) and eye clinic staff e.g. ECLO/Sight Loss Advisor Additional information for the patient’s local council (delete as appropriate) If you are an adult do you live alone? Yes/No Does someone support you with your care? Yes/No Do you have difficulties with your physical mobility? Yes/No Do you have difficulties with your hearing? Yes/No Do you have a learning disability? Yes/No Do you have a diagnosis of dementia? Yes/No Are you employed? Yes/No Are you in full-time education? Yes/No If the patient is a baby, child or young person, is your child/are you known to the specialist visual impairment education service? Yes/No/Don’t know Record any further relevant information below e.g. medical conditions, emotional impact of sight loss, risk of falls, benefits of vision rehabilitation and/or if you think the patient requires urgent support and reasons why. Patient’s information and communication needs All providers of NHS and local authority social care services are legally required to identify, record and meet your individual information/communication needs (refer to Explanatory Notes paragraphs 9, 22 and 23). Preferred method of contact telephone, email or letter? Preferred method of communication e.g. BSL, deafblind manual Preferred format of information (circle all that apply) Large print 18, 22, 26, Easy-Read, Audio CD, Email, Other (specify), I don’t know and need an assessment Preferred language (and identify if an interpreter is required) Page 5 Part 4: Consent to share information I understand that by signing this form I give my permission for a copy to be sent to my GP to make them aware of this certificate. My GP name/practice Address Telephone number I give my permission for a copy to be sent to my local council (or an organisation working on their behalf) who have a duty (under the Care Act 2014) to contact me to offer advice on living with sight loss and explain the benefits of being registered. When the council contacts me, I am aware that I do not have to accept any help, or be registered at that time, if I choose not to do so. My local council name Address Telephone number I give my permission for a copy to be sent to The Royal College of Ophthalmologists, Certifications Office at Moorfields Eye Hospital; where information about eye conditions is collected, and used to help to improve eye care and services in the future. I understand that I do not have to consent to sharing my information with my GP, local council or The Royal College of Ophthalmologists Certifications Office, or that I can withdraw my consent at any point by contacting them directly. I confirm that my attention has been drawn to the paragraph entitled ‘Driving’ on page 8 and understand that I must not drive. Signed by the patient (or signature and name of parent/guardian or representative) Page 6 Ethnicity (this information is needed for service and epidemiological monitoring) White 1.English/Northern Irish/Scottish/Welsh/British 2.Irish 3.Any other White background, describe below Mixed/Multiple ethnic groups 4.White and Black Caribbean 5.White and Black African 6.White and Asian 7.Any other Mixed/Multiple ethnic background, describe below Asian/Asian British 8.Indian 9.Pakistani 10.Bangladeshi 11.Any other Asian background, describe below Black/African/Caribbean/Black British 12.African 13.Caribbean 14.Any other Black/African/Caribbean background, describe below Chinese/Chinese British 15. Chinese 16. Any other Chinese background, describe below Other ethnic group 17. Other, describe below Page 7 Information Sheet for patients (or parents/guardians if the patient is a child) Certification Keep your Certificate of Vision Impairment (CVI). It has three main functions: 1. It qualifies you to be registered with your local council as sight impaired (partially sighted) or severely sight impaired (blind). 2. It lets your local council know about your sight loss. They should contact you within two weeks to offer registration, and to identify any help you might need with day-to-day tasks. 3. The CVI records important information about the causes of sight loss. It helps in planning NHS eye care services and research about eye conditions. Registration and vision rehabilitation/habilitation Councils have a duty to keep a register of people with sight loss. They will contact you to talk about the benefits of being registered. This is likely to be through the Social Services Local Sensory Team (or an organisation working on their behalf). Registration is often a positive step to help you to be as independent as possible. You can choose whether or not to be registered. Once registered, your local council should offer you a card confirming registration. If you are registered, you may find it easier to prove the degree of your sight loss and your eligibility for certain concessions. The Council should also talk to you about vision rehabilitation if you are an adult, and habilitation if you are a child or young person and any other support that might help. Vision rehabilitation/habilitation is support or training to help you to maximise your independence, such as moving around your home and getting out and about safely. Early Years Development, Children and Young People and Education Children (including babies) and young people who are vision impaired will require specialist support for their development and may receive special educational needs provision. An education, health and care (EHC) plan may be provided. You do not need to be certified or registered to receive this support or an EHC plan. This support is provided by the council’s specialist education vision impairment service. Additional support from a social care assessment may also be offered as a result of registration. Information about the support your council offers to children and young people can be found on the ‘Local Offer’ page of their website. If you or your child are not known to this service talk to the Ophthalmologist or ECLO/Sight Loss Advisor. Page 8 Driving As a person certified as sight impaired or severely sight impaired you must not drive and you must inform the DVLA at the earliest opportunity. For more information, please contact: Drivers Medical Branch, DVLA, Swansea, SA99 1TU. Telephone 0300 790 6806. Email eftd@dvla.gsi.gov.uk Where to get further information, advice and support “Sight Loss: What we needed to know”, written by people with sight loss, contains lots of useful information including a list of other charities who may be able to help you. Visit www.rnib.org.uk/sightlossinfo ‘Sightline’ is an online directory of people, services and organisations that help people with sight loss in your area. Visit www.sightlinedirectory.org.uk Your local sight loss charity has lots of information, advice and practical solutions that can help you. Visit www.visionary.org.uk RNIB offers practical and emotional support for everyone affected by sight loss. Call the Helpline on 0303 123 9999 or visit www.rnib.org.uk Guide Dogs provides a range of support services to people of all ages. Call 0800 953 0113 (adults) or 0800 781 1444 (parents/guardians of children/young people) or visit www.guidedogs.org.uk Blind Veterans UK provides services and support to vision impaired veterans. Call 0800 389 7979 or visit www.noonealone.org.uk